Failure to Implement Lockout Tagout Procedures Linked To Severe And Fatal Injuries

June 14, 2022 4 min read

In November 2021, OSHA reported three workers who had severe injuries in two separate incidents related to the failure to implement controls for unintentional energization of equipment during servicing. Later that month, a production manager was trapped in a thermoforming machine when the conveyor cycled automatically, leading to fatal injuries.

These stories have one overarching lesson: failure to implement lockout tagout procedures can lead to severe and fatal injuries. In addition, both companies faced fines and citations from OSHA as a result of their failures. This article discusses the two incidents to show how crucial it is for industries to implement lockout tagout procedures strictly.

Failure to Implement LOTO Procedures Linked to Severe Injuries

OSHA received an employer-reported referral from a southern Illinois tire plant after a worker trying to unjam a machine had his fingers amputated. The following day, a worker from the same plant suffered severe burns that required hospitalization, and another sustained a concussion injury after the explosion of an industrial rubber-compound mixer.

According to the investigation, these severe injuries are related to the lack of combustible dust hazards prevention, failure to guard moving equipment, and the failure to implement procedures to control the unintentional energization of equipment during servicing.

OSHA found that the company had insufficient safety procedures for personal protective equipment, hazard communication, emergency egress routes, housekeeping, combustible dust preventive engineering, and control of hazardous energy or lockout tagout procedures.

Aside from the immense responsibility of the company over the injured workers, OSHA issued the company citations for two repeated, 16 serious, and five other-than-serious violations. With such violations, the company faces  $341,866 in proposed penalties. These are just a fraction of the direct and indirect costs of failing to comply with OSHA safety standards and practices.

Failure to Implement LOTO Procedures Linked To Fatal Injuries

It was supposed to be a typical day for the production manager, who attempted to clear plastic parts stuck in a thermoforming machine. However, OSHA reported that the worker was trapped and fatally crushed when the machine’s conveyor automatically cycled.

During the investigation, OSHA found that the company continued to conduct maintenance and service jobs while machine parts moved after opening an interlocked machine enclosure door. According to OSHA, the company also had insufficient energy control procedures and lacked practical training and retraining of their workers.

“Our investigation found that the company removed jams and performed other service and maintenance tasks with the knowledge that its inadequate and failing lockout tagout procedures exposed its workers to the risks associated with moving machine parts,” said Larry Johnson, OSHA Area Director in Columbus, Ohio.

As a result, OSHA’s verdict was to cite one repeat, one willful, five serious, and two other safety violations against the company.  OSHA also proposed  $291,086 as a penalty. OSHA noted that this accident would have been prevented if the company had corrected failures leading to the incident.

OSHA Control of Hazardous Energy

As OSHA’s Area Director Aaron Priddy in Fairview Heights said during the investigation of the incident in the tire plant, “OSHA standards are put in place to prevent workers from suffering life-altering injuries.” The two incidents cited in this article both had issues with applying the control of hazardous energy safety standards that OSHA has set.

The OSHA standard for the  control of hazardous energy or lockout / tagout (29 CFR 1910.147) establishes the responsibility of employers to protect their workers from hazardous energy.

Specifically, this standard identifies actions and procedures for addressing and controlling hazardous energy during machine and equipment servicing or maintenance. This standard also requires employers to train and retrain each employee to make sure that they know, understand, are aware, and can effectively apply the provisions of hazardous energy control procedures.

Importance of Implementing Lockout Tagout Procedures

According to OSHA, if the employer of the production manager who incurred fatal injuries had been able to remedy failures that contributed to the incident, they would have prevented the tragedy. In other words, fatal injuries could have been avoided if the company had implemented safety standards and practices efficiently. The same is true with the tire plant incidents.

If both companies had implemented efficient lockout tagout procedures, the workers would not have suffered from severe and fatal injuries. Moreover, the companies would not face citations and penalties from OSHA.

Following lockout tagout standards and procedures can keep workers safe, save employees’ lives, prevent severe damage to the equipment and machines themselves, and ensure OSHA compliance. Overall, between the employer, worker, and OSHA, the employer benefits the most from implementing lockout tagout procedures and other safety practices

A Wake-Up Call

OSHA’s Area Director Aaron Priddy in Fairview Heights noted that the tire plant “must learn from these tragic injuries, review company safety procedures and employee training, and make sure workers are safe on the job.” The same goes for the other company cited in this article.

Overall, severe and fatal injuries can be prevented through the effective implementation of lockout tagout procedures. These incidents serve as a wake-up call and a stern reminder for industries to strictly follow OSHA’s standards for safety practices, especially in implementing lockout tagout procedures.

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Herbert Post

Born in the Philadelphia area and raised in Houston by a family who was predominately employed in heavy manufacturing. Herb took a liking to factory processes and later safety compliance where he has spent the last 13 years facilitating best practices and teaching updated regulations. He is married with two children and a St Bernard named Jose. Herb is a self-described compliance geek. When he isn’t studying safety reports and regulatory interpretations he enjoys racquetball and watching his favorite football team, the Dallas Cowboys.


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